|
|
 |
|
|
UPPER PENINSULA HEALTH PLAN
|
|
|
|
Provider Notes
|
|
|
|
Congratulations to Provider Survey Winner!
Thank you to all who took the time to respond to our 2001 Annual Provider Surveys. We appreciate your input and comments! One happy respondent is our Palm Pilot IIIC winner, Dr. Boud Manges from Lambert Health Clinic in St. Ignace. He will be enjoying the
convenience of his handheld computer (if his staff doesn’t take it away from him)!
Following is a summary of the results; if you would like more information, please call Marcie Jones in Clinical Services.
The survey assessed provider satisfaction with UPHP staff and utilization
management processes and with the coordination of care between providers. Primary care providers, specialty care providers, and office staff were surveyed.
Overall, the majority of respondents were “very satisfied” to “satisfied” with UPHP services and with the exchange of information between health care
providers. 82% of respondents were “satisfied” to “extremely satisfied” in all categories combined. Most of the “not satisfied” responses pertained to the
authorization process for nonformulary medications. Many of the comments also pertained to this issue.
With these survey results, the UPHP Clinical Advisory Committee identified
opportunities for improvement in the drug authorization process and formulary, as well as coordination of care between providers. Satisfaction with coordination of
care was high (between 85% and 95% for all provider types); however, improving these results will be one of several quality projects in the coming year.
|
|
|
|
|
|
New Formulary List Is Coming
The UPHP Clinical Advisory Committee reviewed and approved the new formulary at the June 12th, 2001 meeting. Our pharmacy benefit manager will finalize the formulary revisions and print the
new formulary list in July. We will send each office the new list by the end of July 2001. If for some reason you do not receive one by the end of July, please contact our Customer Service department.
UPHP Customer Service 1-800-835-2556
|
|
|
Top
|
|
|
|
|
 |
|
|
|
Quality and Utilization Projects for 2001-2002
Th e June 12, 2001, UPHP Clinical Advisory Committee (CAC) approved the
quality and utilization goals and objectives for 2001-2002. These goals are congruent with those established by MDCH and address issues identified by Health Plan Employer Data and Information Set (HEDIS),
External Quality Review (EQR), and member and provider surveys. Briefly, the projects will be focused on improving the rates of preventive services,
Maternal Support Services/Infant Support Services (MSS/ISS) screenings, and well-child services; and on improving diabetes care, asthma care, management of
depression, coordination of care between providers, and member an provider satisfaction. Utilization projects will focus on identifying overutilization and under
utilization of services. Guidelines for the treatment of respiratory tract infections will be discussed at the September 11, 2001, UPHP CAC meeting, and a study
will be conducted in accordance with the guidelines. These guidelines will be distributed to all appropriate providers as the UPHP CAC approves them. For
more information on these quality and utilization initiatives, please contact Marcie Jones, Dr. Mlsna or Dr. Lorinser in Clinical Services.
|
|
|
|
|
|
|
|
Low Enrollment for Prenatal Smoking Cessation
The Michigan Department of Community Health (MDCH) recently reported low enrollment in the smoking cessation initiatives geared toward pregnant women who smoke within the last six months. The Center for Disease
Control (CDC) sta tistics indicate that smoking levels of pregnant women in Michigan exceed
those in other states (national average: 13.2%; Michigan 17.4%). Seven counties in the Upper Peninsula were reported to have an over 40%
smoking rate for Medicaid women giving birth, as reported on birth certificates.
The Upper Peninsula Health Plan would like to urge our providers to double their
efforts in this regard. In conjunction with your own counseling efforts, please refer to the Maternal Support Services (MSS) programs for Michigan’s Smoke Free Baby and Me program, or we ask you to consider training in the program
yourself.
To learn more about this program, you can reference the Michigan Department of Community Health web site at http://www.mdch.state.mi.us (choose Community
Living Children and Families, then choose Family and Community Health, and finally choose Prenatal Smoking Cessation).
If you are interested in finding out more about this program, please contact UPHP
MMS/ISS Coordinator Della Slavsky in Clinical Services. For further information, contact Aurea Booncharoen at the Michigan Department of Community Health at 517-335-9750. Her e-mail address is BooncharoenA@state.mi.us.
|
|
|
|
 |
|
|
|
External Quality Review (EQR) 2001
The Michigan Department of Community Health (MDCH) contracts with the Michigan Peer Review Organization (MPRO) to perform an annual independent review of the care provided to Medicaid recipients enrolled in Qualified
Health Plans. MDCH requires that the health plans assist MPRO in this process by obtaining the necessary medical records for the MPRO audit.
 As a provider, you may be required to copy medical records and forward them to UPHP, or if your particular office has a sufficient
number of records, MPRO nurse abstractors may conduct the medical record review at your site.
UPHP would like to make this process as convenient as possible for you. We will
contact your office as soon as we are notified by MPRO of the records they will be auditing. This is expected to take place in July and August 2001.
Thank you in advance for your assistance and cooperation in this project. If you have any questions, please feel free to contact Marcie Jones or Tina Peterson in Clinical Services.
|
|
|
|
|
|
Referral Confirmation Letters
In response to our recent provider survey and recommendation from the UPHP Clinical Advisory Committee, UPHP will discontinue sending confirmation letters to the primary care provider (PCP). The referred-to
specialist will continue to receive the letters. UPHP is continually striving to cut down on your paperwork and streamline operations. Thank you for you input.
UPHP strives to cut down on paperwork
|
|
|
Top
|
|
|
|
|
Ongoing Quality Improvement Efforts for Immunizations
We recently completed a Michigan Childhood Immunization Registry (MCIR) audit to assess accuracy in compliance with use of MCIR. Our ability to utilize MCIR data would eliminate the need for us to request
records from you when we complete an immunization study.
|
|
|
|
|
RESULTS
|
RECOMMENDATIONS
|
- Completed series of all vaccinations present in the MICR database: 35%
- Completed series of all vaccinations present in the medical record: 58% (These records could be from PCP and health departments combined.)
- Percentage of members who had PCP medical record documentation for a completed series: 36%
- Varicella: 19% were missing only the varicella; otherwise, the series would have been complete.
|
- Use any opportunity you have to update the medical record and MICR database to assure that all immunizations are completely and accurately documented.
- Make sure that you include all given vaccinations on your submitted claim so that this care is captured on the HEDIS “Quality Reports” as explained in the article
below.
|
|
|
Top
|
|
|
|
|
|
|
|
|
|
|
|
Do You Know...?
Do you know that coding can affect the results on provider quality reports?
For instance, the most recent Health Plan Employer Data and  Information Set (HEDIS) data show that only 2 out of 557 children have had complete Combination-1 immunization series. We know that this is
inaccurate, but since HEDIS looks at claims data to derive this number, we can be fairly sure these immunizations are not always being coded and submitted on the claims.
Do you know that a well-child visit is reimbursable?
Another area that is more than likely affected by coding is well-child visits. As a
whole, the health plan shows low utilization for well-child services. These services are a HEDIS measure as well, and are also captured by claims data. Complete
and accurate coding not only helps to reflect the true picture of services provided, but will also assure that you are adequately and appropriately reimbursed. If you
have any questions about HEDIS, please contact Carolyn Hilden, Tina Peterson, or Marcie Jones in Clinical Services. If you have questions about appropriate coding, please contact our Claims Department.
Submitting appropriate codes on claims ensures accurate quality reporting!
|
|
|
Top
|
|
|
|
|
|
|
|
Watch for Changes to the MSA Cards
As of May 2001, the Medical Services Administration (MSA) card will show Upper Peninsula Health Plan members enrolled in Level of Care 7, with the title “HMO Enrollee.” The MSA card is the light blue card that the
state mails monthly to eligible beneficiaries. Prior to the change, UPHP was listed as Level of Care 11, with the title “Clinic Plan.” These changes in title and Level of Care reflect UPHP’s licensure as an HMO with
the State of Michigan June 20, 2000. Our benefits, services, and health care providers have not been modified because of our status change. If you have any questions, please contact the Customer Service department.
|
|
|
|
|
Transplant Case
Management
|
|
Transplant services require early intervention by case management to optimize the members outcome. UPHP asks all primary care providers and specialists to notify Clinical
Services as soon as a member is identified as a potential organ transplant recipient.
|
|
|
|
|
Medicaid Reimbursement Fees
We receive many requests from providers for the Medicaid reimbursement fee screens. The Michigan Department of Community Health has the current Medicaid reimbursements, by procedure code, listed on its web site.
Please go to www.mdch.state.mi.us/msa/mdch_msa/medicaid_data.htm for this information.
|
|
|
|
Inpatient Claims to Be Processed by UPHP
As of May 1, 2001, UPHP began processing inpatient claims. All inpatient  admissions dated May 1, 2001, or later should be billed to the Upper
Peninsula Health Plan (UPHP), as outpatient claims have been. UPHP will reimburse these claims by the Diagnostic Related Group (DRG) rates, just as the state was doing. The Medical Services Administration
(MSA) inpatient guidelines for UB92 billing will be followed. There will be no changes in the authorization process, although state authorization/pacer numbers
will no longer exist. All inpatient claims can be billed as a hard copy or electronically. For more information on inpatient billing or to check a claims status, please call UPHP’s Claims Department.
|
|
|
|
|
|
|
|
|
Corrections to the
Provider Manual
|
|
Please make the following corrections to your offices copy of the current Provider Manual on page 3.15. The telephone number for substance abuse services in Baraga,
Houghton, and Keweenaw counties is 1-888-482-4097. The telephone number for substance abuse services in Dickinson and Iron counties is 1-888-779-0095. Please contact UPHP’s Customer Service
department if you have any questions.
|
|
|
|
|
you get a denial for a claim and feel it is an error, please call UPHP Customer
Service for assistance. There are numerous reasons why this may occur, but we can help! Please call 1-800-835-2556 when this happens. We will help you to determine if the denial is appropriate and
take the steps to correct it, if necessary. We understand that this may be inconvenient for you; unfortunately, it is occasionally beyond our control. That
is why we ask you to contact us right away if you are receiving a denial in error. We want to help make your job as easy as possible.